Our fifteenth white paper is, "Preparedness and Unpreparedness: The Military vs. Medicine," by Meredith Rosenthal and David Jones.
As the COVID-19 pandemic intensified in the spring of 2020, many Americans were shocked to see how quickly hospitals were overwhelmed in affected cities. Our medical and public health infrastructure was clearly not prepared, leading to problems with emergency medical services, acute care hospitals, nursing homes, access to adequate protective equipment, and mortuary capacity. How could this be? For several decades, the United States government has run pandemic simulations and this outcome— overwhelmed health care systems—has been identified as a possible scenario time and time again. Yet preparations for this eventuality were halting and inadequate at best. In this essay we review the historical and policy contexts of pandemic preparedness to understand why we have been caught off- guard by something we had repeatedly foreseen. We explore the reasons for our current predicament and whether alternative approaches ought to be pursued. It is not that preparedness is impossible: the federal government invests substantial resources in military preparedness, seemingly with good effect. The problem is specific to health care and bears the imprint of our fragmented systems of financing and government oversight. One problem is that responsibility for medical and public health preparedness is not clearly delineated, leading to a patchwork of federal, state, and private (e.g., hospital and other health care institutions) systems. Another is that our systems of hospital finance favor efficiency and optimization of capacity for routine conditions and elective procedures. Hospitals, most of which are pri- vate entities, have no incentive to invest in substantial reserve capacity, and in fact have incentives not to. Moreover, excess capacity could encourage low-value care in non-pandemic times with important consequences for long-run affordability in the most expensive health care system in the world. A third problem is the systematic under-funding of public health infrastructure that has left cities and states unable to do the testing and contact tracing needed to get the epidemic under control. Our systems were set up with an expectation of scarcity and rationing when stressed, and that is what we have ex- perienced. We suggest a series of possible reforms that could be made to improve our preparedness for the inevitable future epidemics.